5 Services Vision Care Two exams per year. Daily-wear contacts or standard glasses (in-plan frames). Members under age 21 are covered for 4 lenses and 2 frames per year. Members age 21 and over are covered for 2 lenses and 1 frame per year. In-plan frames are covered in full. Out-of-plan frames are covered up to $20; member must pay cost over $20. Medically necessary exceptions can be made. Benefit Limits Most benefit limits do not apply if you are pregnant, under age 21 or in a nursing home. Covered Benefit Outpatient Visits (ex. doctor, podiatrist, chiropractor) Inpatient Medical Rehabilitation Hospital Prescription Assistance Up to 18 visits per year 1 admission per year Adults can receive up to 6 prescriptions per month, including refills Dental Limited for adults over 21 31

6 Benefit Limits (cont.) The yearly limits on your medical care refer to services received between July 1 and June 30 of following year. The yearly limits will start again on July 1 of every year. Your provider can ask UnitedHealthcare Community Plan to approve services above these limits for you. This is called an exception. An exception can be granted if: You have a serious chronic illness or health condition and without the additional service, your life would be in danger; or You have a serious chronic illness or health condition and without the additional service, your health would get much worse; or You would need more expensive services if the exception is not granted; or, It would be against federal law for UnitedHealthcare to deny the exception. To have your provider ask for an exception, call UnitedHealthcare Community Plan at , or send your request to: Member Services UnitedHealthcare Community Plan 1001 Brinton Road Pittsburgh, PA We will let you know whether or not the exception is granted within the time listed below. If your provider asks for an exception before you receive the service, you will get a response within 21 days of the date we get the request. If your provider asks for an exception before you receive the service, and your provider tells us you have an urgent need for a quick response, you will get a response within 48 hours of the date and time we get the request. If your provider asks for an exception after you received the service, you will get a response within 30 days of the date we get the request. If you disagree with the response you get from UnitedHealthcare Community Plan, you can file a complaint or a grievance. You can file a complaint with UnitedHealthcare Community Plan if you think you were charged the wrong copay or if a service is denied and you think you have not reached the limit. You can file an appeal if you or your provider asks for an exception and the exception is denied. You can also ask for a DPW fair hearing. 32 Medicaid Member Handbook

7 Non-Covered Services There are some things that UnitedHealthcare Community Plan does not cover. These include: Care for which you do not have a referral, except for self-referral services and emergency care. Care from out-of-network providers who are not prior-approved, except for emergency or family planning services. Services covered by other insurance, worker s compensation or programs like Veterans Administration. Boarding home expenses (residential care that is not medically necessary). Experimental procedures. Infertility services. Mental health or drug and alcohol treatment services (covered by your HealthChoices behavioral health plan). Skilled nursing or intermediate care facilities over 30 consecutive days. Members will be disenrolled from UnitedHealthcare Community Plan and placed into Fee-For-Service after 30 consecutive days in a skilled nursing facility. Personal convenience items (telephone, television, etc.) while in a hospital room, unless medically necessary. Plastic or cosmetic surgery, except in case of injury or surgery that causes disfigurement. Prescription drugs for members over age 21 who are eligible for only limited Medical Assistance benefits. Services that are not medically necessary. 33

bortion and related BP cupuncture llergy testing Except when performed as anesthesia for an approved surgery. with udiology Limited children under the age of 16 years. Limited $1,000 per ear every 24 months.

WHO IS COVERED Requires both Medicare A & B enrollment. Type of Coverage Offered Single only Single only MEDICAL NECESSITY Pre-Certification Requirement None None Medical Benefit Management Program Not

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SU Pro ( and ) Annual Deductible 1 Coinsurance Cost Sharing Definitions $200 per individual with a maximum of $400 for a family 5% of allowable amount for inpatient hospitalization - or - 50% of allowable

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